Get Il Blue Cross Blue Shield Initial Assessment Request 2018

Filling out the IL Blue Cross Blue Shield Initial Assessment Request online allows users to initiate their assessment process efficiently. This guide provides step-by-step instructions to help users complete the form accurately and effectively, ensuring all essential information is captured.

Follow the steps to fill out the IL Blue Cross Blue Shield Initial Assessment Request online

1. To begin, locate and press the ‘Get Form’ button to access the IL Blue Cross Blue Shield Initial Assessment Request form. Open it in your digital editor to start filling out the necessary information.
2. In the 'Patient Info' section, fill in the patient's name, date of birth, request submission date, subscriber name, subscriber ID, and group information. Indicate the state where the patient resides and confirm whether services will be conducted in the same state.
3. For the 'Diagnostic Practitioner Info', input the diagnostic practitioner's name, NPI number, telephone, fax, and contact name. Select the appropriate type of practitioner based on the specialties mentioned.
4. Next, provide the primary and secondary diagnosis codes along with the dates of the initial evaluations. Ensure that this information is accurate for proper assessment.
5. In the 'Authorization/Communication Sent To' section, fill in the facility's name, NPI, address, city, state, zip code, telephone number, and contact name. If different, also include the BCBA's information.
6. For the 'Provider Request', detail the assessment request start and end dates. Specify the ABA assessment codes, ensuring to indicate the total units for the assessment period.
7. In the 'Certification of Provider Qualifications' area, the ABA supervisor must sign and date the form. Additionally, input the supervisor's printed name and clinic name.
8. Finally, review all information entered for accuracy. Once confirmed, save the changes to your document. You can then download, print, or share the completed form as necessary.

Complete your IL Blue Cross Blue Shield Initial Assessment Request online today for a streamlined process.